Edited with the trial version of

Foxit Advanced PDF Editor

To remove this notice, visit:
www.foxitsoftware.com/shopping

Kumari Securities Pvt. Ltd. cg';"rL–!@

Broker No.: 1 -lgod @( sf] pklgod -!_ ;+u ;DalGwt_
Dillibazar, Kathmandu
Tel: +977-1-4418036
k|fs[lts JolQmsf] kl/ro ljj/0f
Details of Natural Person

sfof{no k|of]hgsf] nflu dfq (For Official Use Only)

u|fxs g+=M ;+s]t gDa/ M ldlt M
Client's A/c No.: Reference No.: Date :

tn pNn]lvt ;Dk"0f{ ljj/0f /fd|f;] Fu eg'{ kg]{5 . cfkm";Fu ;/f]sf/ gePsf] ljj/0f pNn]v ug]{ sf]7fdf
t];|f] wsf{ tflglbg' xf]nf .
Please complete all details and strike out the non-applicable fields/boxes. xfn;fn}
lvlrPsf] kmf]6f]
s'df/L ;]So"l/6Lh -k|f=_ ln= PP Size Photo
(Recent)
Kumari Securities Pvt. Ltd.
======================================= -zfvf_

u|fxssf] ljj/0f (Details of Client)

gfd
Name (In Block Letter)
hGd ldlt la=;+= O{= ;+=
Date of Birth B. S. A. D.
ln· k'?if dlxnf cGo ljjflxt cljjflxt
Gender Male Female Others Married Un Married

/fli6«otf g]kfnL cGo -v'nfpg]_

Nationality Nepalese Others (If any)
gful/stf gDa/ hf/L lhNnf hf/L ldlt
Citizenship No. Issue District Issue Date

lxtu|fxL vftf vf]lnPsf] ;+:yfsf] gfd

lxtu|fxL vftf g+=
Beneficiary ID No.
:yfoL n]vf g+=
Permanent Account No. (PAN)
u}/cfjfl;o g]kfnLsf] xsdf
kl/rokq g+= / 7]ufgf
Identification No. and address (In case of NRN)

xfnsf] 7]ufgf (Current Address)

b]z M k|b]z M lhNnf M
Country : Province : District :
uf=kf=÷g=kf=÷p=d=g=kf=÷d=g=kf= j8f g+=M
Rural Municipality/Municipality/
Sub Metropolitan city/ Ward No.:
Metropolitan city

6f]n M 6]lnkmf]g g+=M

Tole : Telephone No.:
O{d]n M df]afOn g+=M
E-mail ID : Mobile No.:

:yfoL 7]ufgf (Permanent Address)

k|b]z M lhNnf M
Province : District :
6f]n M uf=kf=÷g=kf=÷p=d=g=kf=÷d=g=kf=
Rural Municipality/Municipality/
Tole : Sub Metropolitan city/
Metropolitan city
6]lnkmf]g g+=M j8f g+=M Ans g+=M
Telephone No.: Ward No.: Block No.:
Page 1 of 4
 Edited with the trial version of
Foxit Advanced PDF Editor
To remove this notice, visit:
www.foxitsoftware.com/shopping

kl/jf/sf ;b:ox?sf] ljj/0f -7fp“ gk'u ePdf yk ug{ ;lsg]_ (Details of Family Members)
a'afsf] gfd
Father's Name
(In Block Ltter)
afh]sf] gfd
Grand Father's Name

cfdfsf] gfd
Mother's Name

klt÷kTgLsf] gfd
Spouse's Name

5f]/fsf] gfd

Son's Name

5f]/Lsf] gfd
-cljjflxt_

Daughter's Name

a'xf/Lsf] gfd

Daughter's in Law's
Name

;;'/fsf] gfd -ljjflxt

dlxnfsf] xsdf_
Father in Law's
Name
;f;'sf] gfd -ljjflxt
dlxnfsf] xsdf_
Mother in Law's
Name

a}+s vftfsf] ljj/0f (Bank Account Details)

a}+s vftfsf] lsl;d M art vftf rNtL vftf
Types of Bank Account : Saving Account Current Account
a}+s vftf gDa/ M
Bank Account Number :
a}+s vftf ePsf] a}+ssf] gfd / 7]ufgf M
Name & Address of Bank :

k]zfut ljj/0f (Details of Occupation)

k]zf M ;]jfM ;/sf/L ;fj{hlgs÷lghL If]q Pg=hL=cf]=÷cfO{ =Pg=hL=cf]= ljz]if1 ljBfyL{
Occupation : Service: Govt. Public/Private Sector NGO/INGO Expert Student
Jofkf/L s[lif ;]jf lgj[Q u[lx0fL cGo
Businessperson Agriculture Retired House Wife Others

Jofkf/sf] k|sf/ M pTkfbg ;]jfd' vL cGo

Types of Business : Manufacturing Service Oriented Others
;+:yfsf] gfd M 7]ufgf
Organization's Name : Address
kb M sd{rf/Lsf] xsdf sd{rf/L kl/rokq g+=M
Designation : (ID No of Employee)
Page 2 of 4
 Edited with the trial version of
Foxit Advanced PDF Editor
To remove this notice, visit:
www.foxitsoftware.com/shopping

cfly{s ljj/0f M cfosf] ;Ldf -jflif{s ljj/0f / Income Limit (Annual Details)
Financial Details : ?= %,)),))) ;Dd ?= %,)),))! b]lv ?= !),)),))) ;Dd ?= !),)),))) eGbf dfly
Upto Rs. 5,00,000 From Rs. 5,00,001 to Rs. 10,00,000 Above Rs. 10,00,000

sf/f]af/ ;DalGw yk ljj/0f (Transaction related additional information)

!= cfDbfgLsf] >f]t 3 nufpg' xf]; M Joj;foLs cfDbfgL tna÷kfl/>lds nufgL k|ltkmn 3/ ef8f lwtf]kq sf/f]jf/
ljk|]if0f k}t[s Aofh cGo pNn]v ug'{xf]; ========================================================================================
@= cGo lwtf]kq bnfn sDkgLdf sf/f]jf/ ug]{ u/]sf] M 5}g 5
5 eg] sDkgLsf] gfd M ================================================================================== u|fxs sf]8M =======================================
#= tkfO{ shf{ ;"rgf s]Gb| -;'/If0f lgud_ ln= sf] sfnf];'rLdf /xg' ePsf] 5 < 5}g 5
lwtf]kq vl/b laqmL ug]{ d'Vo p2]Zon] :yflkt OGe]i6d]G6 sDkgLdf ;+nUg
5' 5}g .
Involvement in Investment companies which were established for securities trading
Yes No
-ePdf b]xfo adf]lhdsf] ljj/0f pNn]v ug'{ kg]{ . (If yes mention below)
sDkgLsf] gfd M
Name of the Company :

kb M ;~rfns kbflwsf/L z]o/wgL sd{rf/L cGo

Designation : Director Executive Shareholder Employee Others

axfndf a:g] s f] xsdf

3/ wgLsf] gfd M ===========================================================================================================================
6]lnkmf]g g+= ==================================== df]afO{n g+= ====================================== lhNnf M========================================
dgkf÷pkdgkf÷gkf÷uflj;M==========================================================================================j8f g+=M===============
;+/Ifssf] kmf]6f]
6f] nM======================================================== 3/ g+= M======================= -xfn;fn}
lvlrPsf]_
;+/Ifssf] ljj/0f -gfafns÷ljlIfKtsf] xsdf dfq_ Guardian's Details (In case of Minor/Intellectually Disabled only)

gfd÷y/ M
Name/Surname : (In Block letter)
lgj]bs;+usf] ;DaGw M
Relationship with applicant :
kqfrf/ 7]ufgf M
Correspondence Address :
b]z M k|b]z M
Country : Province :

lhNnf M uf=kf=÷g=kf=÷p=d=g=kf=÷d=g=kf=
Rural Municipality/Municipality/
District : Sub Metropolitan city/
Metropolitan city
j8f g+=M 6]lnkmf]g g+=M
Ward No.: Telephone No.:
km\ofS; g+=M df]afOn g+=M
Fax No.: Mobile No.:
:yfoL n]vf g+=M O{d]n M
PAN No.: E-mail ID :

========================================
;+/Ifssf] x:tfIf/
Guardian's Signature

xfn a;f]a f; /x] s f] Site Map

:yfgsf] gSzf N
Þ

Location Map

From main Road Street.................................................................. the distance of the Residence is............ meters (approximately).
Page 3 of 4
 Edited with the trial version of
Foxit Advanced PDF Editor
To remove this notice, visit:
www.foxitsoftware.com/shopping

;DklQ z'l4s/0f tyf cftÍsf/L s[ofsnfkdf ljlQo lgjf/0f ;DaGwL yk ljj/0fM

!= s] tkfO{ /fhg}lts jf pRr kb:y JolQm x'g'x'G5 < xf] xf]O{g
@= s] tkfO{ /fhg}lts jf pRr kb:y JolQm ;+u ;DalGw x'g'x'G5 < 5' 5}g
;DalGwt /fhg}lts÷pRr kb:y JolQmsf] gfd tkfO{;+usf] ;DaGw
==================================================================================================================== ===========================================
#= s] tkfO{sf] lxtflwsf/L JolQm 5 < 5}g 5
lxtflwsf/L JolQmsf] gfd tkfO{;+usf] ;DaGw
==================================================================================================================== ===========================================
$= s] tkfO{ ljutdf s'g} ;Da4 s;'/df bf]ifL k|dfl0ft x'g' ePsf] 5 < 5}g 5
;DklQ z'l4s/0f -dgL nfp08l/·_ lgjf/0f P]g, @)^$ sf] bkmf @ sf] v08 -z_ adf]lhdsf s;'/x?
5 eg] s[kof pNn]v ug'{xf]; ====================================================================================================================================
lwtf]kq sf/f]jf/sf] ;DaGwdf tklzn adf]lhdsf] :j3f]if0ff ub{5' .
!= d÷xfdLn] lwtf]kq vl/bsf nflu k|of]u ug]{ /sd ;DkQL z'l4s/0f %= d÷xfdL shf{ ;"rgf s]Gb|sf] sfnf] ;'rLdf /x]sf] 5'÷5}g .
;DaGwL k|rlnt sfg'g ljkl/t cfh{g u/]sf] x'g] 5}g . ^= ;DklQ z'l4s/0f -dgL nfp08l/·_ lgjf/0f P]g, @)^$ / o;
@= lwtf] k qdf ul/Psf] nufgLdf lglxt hf] l vdsf] ;DaGwdf cGt/ut hf/L ePsf lgodfjln tyf lgb]{zg cfbLaf6 dfu eP
hfgsf/ 5' . cg';f/sf ;'rgf, ljj/0f tyf sfuhftx? sDkgLnfO{ pknAw
#= d÷xfdLn] vl/b u/]sf lwtf]kqx? jfktsf] e'QmfgL lng] lbg] sfo{ u/fpg] 5'÷5f}+ .
tf]lsPsf] ;do leq ug]{ 5' . &= sDkgLnfO{ ug'{ kg] { e' QmfgL gul/ af+s L /fv] sf] sf/0faf6
$= d÷xfdLn] lwtf]kq ;DaGwL tyf cGo k|rlnt lgod sfg"gx?sf] d]/f]÷xfd|f] sf/f]jf/ cGo lwtf]kq bnfn sDkgLx?df ;d]t lgnDag
kfngf ug]{5' . ug{ kqfrf/ jf kl/kq ug{ d]/f]÷xfd|f] d~h'/L 5 .
;+nUg ug'{ kg]{ sfuhft
!= g]kfnL gful/sx?sf] xsdf gful/stfsf k|df0fkqsf] k|ltlnkL . %= cfdf jf afa' ;+/Ifs ePdf 5f]/f jf 5f]/Lsf] hGdbtf{ k|df0fkqsf]
@= cGo b]zsf] gful/ssf] xsdf kf;kf]6{sf] k|ltlnkL . k|ltlnkL .
#= gfafnssf] xsdf ;+/Ifs tyf gfafns b'j}sf] kmf]6f] . ^= lgj]bssf] x:tfIf/ tyf cf}+7f 5fkdf ;+/Ifssf] x:tfIf/ tyf cf}+7f
$= sfg"gL ;+/Ifs eP ;f] ;DaGwL sfuhft . 5fk .
&= s'g} ;+:yfsf] sd{rf/L /x]sf] xsdf sd{rf/L kl/rokqsf] k|ltlnkL .
dfly pNn]lvt ljj/0f ;To tYo /x]sf] / ;f] ljj/0fdf s'g} km/s k/] sfg"g adf]lhd ;x'“nf, a'emfp“nf . I/We hereby acknowledge that
the above disclosed details are true. I further hereby consent to bear any legal actions in case any false disclosure of
information related to me/us.

cf}+7f 5fk Thumb Print

bfof“ Right afof“ Left

=================================
u|fxssf] x:tfIf/
Client's Signature

sfof{no k|of]hgsf] nflu (For Official Use)

?h' ug]{M k|dfl0ft ug]{ M
gfd, y/ M gfd, y/ M
kb M kb M
x:tfIf/ M x:tfIf/ M
ldlt M sfof{nosf] gfd tyf 5fk ldlt M

========================================
k|lji6L ug]s { f] x:tfIf/

l;kmfl/; stf{sf] gfdM ====================================================

kmf]g g+=M =============================================
Page 4 of 4